Reaction to the article on the double burden of obesity and malnutrition in Western Sahara refugees

Dear editors

One of the key challenges that the nutrition
community faces in this century is
the double burden of nutrition. In many
countries, it is found that acute malnutrition
continues to pose a public health
problem while overnutrition is becoming
more and more of a problem as well. The
article in the last issue of Field Exchange
(No. 44, December 2012) on the study by
Grijalva-Eternot et al1 shows that the
problem of co-existence of obesity and
malnutrition even appears to be present
in a refugee camp setting.

The Sahrawi camps in the desert area
in the far south-west of Algeria are one
of the most protracted refugee situations
worldwide that has existed for over 35
years. International support has always
been provided on a ‘care and maintenance’
basis, with most of the funding
going to the food and nutrition sector.
As part of a recent consultancy assignment
in the Sahrawi refugee camps, I
looked into the findings of some key
food and nutrition studies in the
Sahrawi camps2.

These studies show that most Sahrawi
refugees still depend on food aid, but
that there actually is an unusually varied
basket of food commodities. There is a
full general ration distribution (2100 kcal
p.p.p.d), complementary year-round
distribution of rations of green tea and
dried yeast, and a separate distribution
system for fresh vegetables. An additional
programme exists for provision of
fresh foods during Ramadan. This is
complemented by programmes for treatment
of severe acute malnutrition
(SAM), treatment of moderate acute
malnutrition (MAM), supplementary
feeding for pregnant/lactating women,
targeted supplementary feeding for
selected elderly and handicapped, distribution
of NutriButter/micronutrient
powder (MNP) in relation to the 1,000
days approach, and a school feeding
prog-ramme.

It was shown in the studies
mentioned above that the core of the diet
is coming from food aid and the complementary
nutrition programmes. The package is well-balanced in terms of
nutrients. It is noteworthy that dietary
diversity was rated to be sufficient. To
some extent, this is because most
refugees have access to additional food
on top of what is provided through the
aid agencies. This is through engagement
in livestock keeping, bartering of
food aid for other items, buying food in
shops and on the market (using income
from remittances and through daily
labour), produce from small family
gardens, and through sharing and other
forms of social solidarity among relatives
and neighbours.

In this situation, the ultimate solution
to the problem of the double burden of
malnutrition boils down to behavioural
changes. The solution for addressing
malnutrition among children lies in
concerted intensive education campaigns
on appropriate infant and young child
feeding practices. Similarly, the problem
of obesity and anaemia among women
will have to be addressed through
spreading information about what
constitutes a healthy diet. Evidently, at
some point in time, the Sahrawi will
need to abandon their long-held tradition
of fattening of women during
periods of ritual overfeeding, reduce
their excessive consumption of sugar,
and find ways to build in low-intensity
exercise in their daily life, even in a
camp setting. However, as experience
from elsewhere in the world shows,
changing dietary and health practices is
a difficult and long-term process that
usually does not show quick results. In
the meantime it will be necessary to
continue the distribution of fortified
food with various forms of micronutrient
supplementation in the Sahrawi
camps. Also, community based management
of acute malnutrition (CMAM) is a
service still required for treatment. I am
not sure that we have an appropriate
‘quick fix’ in our nutrition toolkit for
reducing obesity in non-Western
settings?